The autoimmune inflammatory disorder, Sjögren syndrome (SS), presents as chronic dry eyes and dry mouth due to decreased lachrymal and salivary gland function.1 While severity widely varies, its features are divided into two categories, glandular and extragrandular. SS can either be a primary disease or secondary to other autoimmune diseases such as rheumatoid arthritis or lupus.
There are three very common symptomatic complaints among patients with SS that can help narrow the differential diagnosis sooner.2 These complaints can significantly contribute to compromised quality of life and occupational impairment.
First, patients with SS often complain of fatigue and/or brain fog. It seems that whatever process we see occurring in the eye or in the mouth in terms of dryness is also interfering with the processing in the brain. This complicated neuropathy, involving both peripheral and central manifestations, are a challenge to patients. Fatigue and brain fog go beyond being just tired; it can interfere with the ability to perform daily tasks and jobs. Concentration can be affected, and dry eyes can lead to an inability to look at computer screens, a common task in modern times. Severe cases can lead to loss of income.
Second, ocular signs and symptoms of SS can also be debilitating. General symptoms are defined as dry eyes for more than 3 months, but patients can also report feeling like a foreign body is stuck in their eye (sometimes referred to as “grainy” sensation). It should also be concerning if patients are using over the counter lubricating eye drops or artificial tears more than 3 times daily for extended periods. These signs determined by a quick Schirmer test at the bedside, though rheumatologists should be careful to not to try and replace the expertise of an ophthalmologist.
The third area of symptomatic complaints occur in the oral cavity. Patients most commonly report a feeling of dry mouth, which is characteristic of the disease. However, patients may also have recurrent swollen salivary glands, including the parotid and submandibular. Another notable complaint of patients is the frequent use of oral liquids to aid in swallowing. Oral signs may be observed as abnormal salivary scintigraphy, parotid sialography, and sialometry findings (ie, unstimulated salivary flow < 1.5 mL in 15 minutes), though these tests are more commonly used in Europe vs the United States.
Instead of European testing methods, US-based clinicians should rely on positive minor salivary gland biopsy findings or positive anti-SSA or anti-SSB antibody results. These results would indicate the autoimmune process. —Robert Fox, MD, PhD
- Baer AN; Fox R, Romain PL, eds. Diagnosis and classification of Sjögren’s syndrome. UpToDate. Updated September 28, 2020. Accessed March 29, 2021. https://www.uptodate.com/contents/diagnosis-and-classification-of-sjogrens-syndrome
- Fox R. Precision medicine in Sjògren’s syndrome. Presented at: Interdisciplinary Autoimmune Summit 2021; April 15-18, 2021; virtual.